Healthy Weight and Your Child
A Healthy Eating and Active Living Program brought to you by the YMCA
Are you a Healthcare Provider wishing to refer a patient?
*
Yes
No
Please select the YMCA that is closest to you
*
YMCA of the Upper Pee Dee (Hartsville, SC)
Summerville Family YMCA
Sumter YMCA
Health Care Provider statement:
*
I know of no reason why the child may not participate
I know the child can participate, but I urge caution (explain below)
The child should not engage in specific activities (explain below)
I recommend the child NOT participate
If you urge caution or recommend the child to not engage in specific activities, please list them below:
Name of Health Care Practice (if not listed, fill out below in the blank)
Please Select
Carolina Pines
CareSouth
Fetter Health
Lamar Medical
Morphus Medical Group
Sumter Pediatrics
Name of Health Care Practice (if not in the drop down list above)
Health Care Provider Name
*
First Name
Last Name
Provider Email (optional)
example@example.com
Health Care Provider Signature
*
Optional: Signed Medical Clearance
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ADULT INFORMATION
Adult Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact Method
*
Email
Mobile - Call
Mobile - Text
Home Phone
PARTICIPANT/CHILD DETAILS
Child Name
*
First Name
Last Name
Child's Preferred Name:
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: